The oblique high tibial osteotomy technique without bone removal and with rigid blade plate fixation for the treatment of medial osteoarthritis of the varus knee: medium and long-term results

Proximal tibia osteotomy with absorbable spacer combined with fibular osteotomy versus high tibial osteotomy for medial compartmental knee osteoarthritis

PURPOSE

The study aimed to compare the perioperative complications, short-term clinical outcomes, patient-reported outcomes, and radiographic parameters of tibiofibular proximal osteotomy combined with absorbable spacer insertion (TPOASI) and open-wedge high tibial osteotomy (OWHTO) in a two year postoperative time period.

METHODS

A total of 160 patients with Kellgren-Lawrence classification grade 3 medial compartmental knee OA were randomized to receive either TPOASI (n = 82) or OWHTO (n = 78). The primary and secondary outcomes were measured preoperatively, postoperatively, and at each follow-up examination. The primary outcomes were the between-group change in the Western Ontario and McMaster Universities Global score (WOMAC). Secondary measures included visual analog scale (VAS), radiographic parameters, American Knee Society Score (KSS), operation time, blood loss, length of incision, hospital stay, and relevant complications. Postoperative radiographic parameters, including the femorotibial angle (FTA), varus angle (VA), and joint line convergence angle (JLCA), were measured to evaluate the correction of varus deformity.

RESULTS

No significant differences were found in the baseline data between the two groups. Both methods improved functional status and pain postoperatively. For primary outcomes of both groups, statistical difference was observed in WOMAC scores at the 6-month follow-up (P < 0.001). For secondary outcomes, no statistical difference was observed between the groups during the 2-year follow-up (P > 0.05). For TPOASI vs. OWHTO, the mean hospital stay (6.6 ± 1.3 days vs. 7.8 ± 2.1 days) was shorter (P < 0.001), and both blood loss (70.56 ± 35.58 vs. 174.00 ± 66.33 mL) and complication rate (3.7% vs. 12.8%) were significantly lower (P < 0.005 for both).

CONCLUSIONS

Both approaches showed satisfactory functional outcomes and alleviated pain. However, TPOASI is a simple, feasible method with few complications, and it could be widely used.

Long-term follow-up results of medial opening wedge high tibia osteotomy with a pre-countered non-locking steel plate

INTRODUCTION

This retrospective study investigated the long-term follow-up results of medial opening wedge high tibial osteotomy (MOWHTO) with a pre-countered non-locking steel plate implant (Puddu plate = PP) used for medial knee osteoarthrosis (OA) treatment.

MATERIALS AND METHODS

Consecutive 70 MOWHTOs (66 patients) were performed between 01.01.2004 and 31.12.2008 with the mean follow-up time of 11.4 (SD 4.5; range 1.2-16.1) years. The Kaplan-Meier survival analysis was used to evaluate the cumulative survival of the implant in terms of age (< 50 years old and ≥ 50 years old) and gender. Adverse events were studied and Cox regression analysis was used to evaluate risk factors [age, gender, body mass index (BMI), preoperative mechanical axis, severity of OA, use of bone grafting or substitution and undercorrection of mechanical axis from varus to valgus] for revisions.

RESULTS

The estimates for the cumulative survival with no need for TKA after MOWHTO were 86% at 5 years, 67% at 10 years and 58% at 16.1 years (SE 0.6, CI 95% 11.1-13.5). A total of 33/70 (47%) adverse events occurred and 38/70 (54%) knees required some revision surgery during the follow-up. Cox regression did not show any statistically significant risk factors for revision.

CONCLUSIONS

The PP has feasible MOWHTO results with a cumulative survival of 67% at 10 years with no need for conversion to TKA. Many adverse events occurred and revision rate due to any reason was high. Age or gender did not have statistically significant differences in terms of survival.

Anterior Proximal-to-Posterior Distal Oblique Proximal Tibial Osteotomy

High tibial osteotomy is a common procedure to address unicompartment knee osteoarthritis and other conditions. Regarding the specific surgical methods, medial open wedge osteotomy and lateral close wedge osteotomy are the most used. Both methods have a common disadvantage in that they are not so suitable to correct a severe deformity. Thus, we would like to introduce an anterior proximal-to-posterior distal oblique proximal tibial osteotomy technique, which is especially suitable to correct severe tibial deformity. The most critical point of this technique is to create an osteotomy plane from the most proximal posterior site of the tibial tubercle posteriorly and distally to the posterior cortex of the tibia, with each horizontal osteotomy maneuver in the coronal plane. Combined fibular osteotomy is always needed, and better results can be obtained when it is combined with arthroscopic debridement of the knee. We consider the introduction of this technique will provide a useful option when tibial osteotomy is needed to preserve the knee, especially for a great deformity correction.

Return to Physical Activity After High Tibial Osteotomy or Unicompartmental Knee Arthroplasty: A Systematic Review and Pooling Data Analysis

BACKGROUND

The 2 most common definitive surgical interventions currently performed for the treatment of medial osteoarthritis of the knee are medial opening wedge high tibial osteotomy (HTO) and medial unicompartmental knee arthroplasty (UKA). Research exists to suggest that physically active patients may be suitably indicated for either procedure despite HTO being historically indicated in active patients and UKA being more appropriate for sedentary individuals.

PURPOSE

To help consolidate the current indications for both procedures regarding physical activity and to ensure that they are based on the best information presently available.

STUDY DESIGN

Systematic review.

METHODS

A search of the literature via the MEDLINE, Embase, and PubMed databases was conducted independently by 2 reviewers in accordance with the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Studies that reported patient physical activity levels with the Tegner activity score were eligible for inclusion. Patient demographics, operative variables, and patient-reported outcome scores were abstracted from the included studies.

RESULTS

Thirteen eligible studies were included, consisting of 401 knees that received HTO (399 patients) and 1622 that received UKA (1400 patients). The patients' mean age at surgery was 48.4 years for the HTO group and 60.6 years for the UKA group. Mean follow-up was 46.6 months (HTO) and 53.4 months (UKA). All outcome scores demonstrated an equal or improved score for activity and knee function regardless of the operation performed. Operative variables during HTO had a larger effect on outcome than during UKA.

CONCLUSION

Patients who underwent HTO were more physically active pre- and postoperatively, but patients undergoing UKA experienced an overall greater increase in their physical activity levels and knee function according to Tegner and Lysholm scores. Activity after HTO may be influenced by operative factors such as the implant used and the decision to include a graft material in the osteotomy gap, although this requires further research. Some studies found that patients were able to return to physical activity postoperatively despite having an age or body mass index that would traditionally be a relative contraindication for HTO or UKA.

Venous Thromboembolism and Bleeding Adverse Events in Lower Leg, Ankle, and Foot Orthopaedic Surgery with and without Anticoagulants

BACKGROUND

Currently, there is insufficient knowledge about the benefits of anticoagulant use for primary prevention of venous thromboembolism (VTE) and its inherent risk of bleeding adverse events in patients undergoing surgery distal to the knee.

METHODS

The study included patients who had undergone an orthopaedic procedure distal to the tibial articular surface when they were 18 years of age or older. Using retrospective information from a tertiary care referral center, we compared patient demographics, clinical findings, diagnostic reports, procedures performed, and the rate of symptomatic VTE and bleeding adverse events between patients who had and those who had not received anticoagulant prophylaxis. Propensity score matching was used to minimize selection bias due to prophylactic treatment allocation.

RESULTS

A total of 5,286 patients who had received anticoagulant prophylaxis for below-the-knee surgery were successfully matched with 5,286 patients who had not received anticoagulant prophylaxis for such surgery. After propensity score matching, the standardized difference between the groups was <0.1 for all baseline characteristics, indicating a negligible difference between the groups. Patients who received anticoagulant prophylaxis had a significantly lower risk of developing a VTE compared with patients who did not (39 patients [0.7%] versus 99 patients [1.9%]), with an odds ratio (OR) of 0.38 (95% confidence interval [CI], 0.25 to 0.56; p < 0.001). In contradistinction, patients who received anticoagulant prophylaxis had a significantly higher risk of developing a bleeding adverse event than those who did not (115 [2.2%] versus 55 [1.0%]; OR, 2.18 [95% CI, 1.55 to 3.09]; p < 0.001).

CONCLUSIONS

Anticoagulant prophylaxis reduced the risk of VTE after surgery distal to the tibial articular surface by 3-fold but resulted in a concomitant 2-fold increase in the risk of a bleeding adverse event. Large-scale, prospective studies are necessary to better understand the true incidence of such events, associated patient-specific risk factors, efficacy of various thromboprophylactic regimens, and patient-reported implications of such events.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Edoxaban is effective in reducing the incidence of asymptomatic phlebographic events following closed-wedge high tibial osteotomy

INTRODUCTION

The purpose of this study was twofold: to investigate whether edoxaban significantly decreases the rate of venous thromboembolism (VTE) following closed-wedge high tibial osteotomy (CWHTO), in terms of phlebographic event, and to determine whether edoxaban is safe or increases the rate of hemorrhagic complications. We hypothesized that edoxaban would decrease the incidence of VTE and would not increase the rate of hemorrhagic complications.

MATERIALS AND METHODS

We randomly enrolled 60 patients undergoing CWHTO. The patients were divided into two groups: one group receiving edoxaban (15mg in 5 patients, 30mg in 23 patients) and a non-edoxaban group. All patients underwent computed tomography venography on day 7to diagnose postoperative VTE. Blood samples were obtained on the day before CWHTO and on postoperative days 1, 3, 7 and 14. The incidence of VTE and hemorrhagic events in both groups was compared using unpaired Student t-test or chi-square test.

RESULTS

The incidence of VTE was significantly greater in the non-edoxaban group (31.3% versus 7.1%; P=0.02). The incidence of deep vein thrombosis (DVT) was also significantly greater in the non-edoxaban group (28.1% versus 3.6%; P=0.01). A single patient from the edoxaban group experienced major bleeding. On days 3 and 7, D-dimer levels were significantly lower in the edoxaban group (P=0.03 and 0.003, respectively). On days 3, 7 and 14, activated partial thromboplastin time was significantly greater in the edoxaban group (P=0.02, 0.01 and 0.006, respectively).

CONCLUSION

Patients undergoing CWHTO are at risk of postoperative VTE. Edoxaban helps prevent asymptomatic phlebographic VTE and DVT following CWHTO; however, the risk of major bleeding must be considered.

LEVEL OF EVIDENCE

II.

The use of factor Xa inhibitors following opening-wedge high tibial osteotomy for venous thromboembolism prophylaxis

PURPOSE

This study aimed to investigate the incidence of venous thromboembolism (VTE) after medial opening-wedge high tibial osteotomy (OWHTO) and evaluate the efficacy and safety of edoxaban for the prevention of VTE in patients undergoing OWHTO.

METHODS

A total of 139 patients with osteoarthritis or osteonecrosis undergoing OWHTO were enrolled in this prospective, randomized study. Four patients were excluded because of preoperatively diagnosed VTE, and 135 patients were divided into two groups-an edoxaban group and a non-edoxaban group-and underwent computed tomography venography on day 7 to check for postoperative VTE. Blood samples were taken on the day before OWHTO and on postoperative days 1, 3, 7, and 14.

RESULTS

Treatment with edoxaban reduced the incidence of VTE after OWHTO; however, there was no statistically significant difference between the two groups. No major bleeding was noted in the edoxaban group. There were significant differences in the D-dimer level, prothrombin time, fibrinogen level, and thrombin antithrombin complex levels between the groups.

CONCLUSIONS

Edoxaban is an oral, once-daily, selective, direct factor Xa inhibitor that is safe and easy to handle. It may offer a new option for preventing VTE after OWHTO.

LEVEL OF EVIDENCE

I.

Long-term results and comparison of the three different high tibial osteotomy and fixation techniques in medial compartment arthrosis

BACKGROUND

The purpose of this study is to report and analyze the long-term outcomes of the patients who underwent high tibial osteotomy (HTO) with three different techniques for the treatment of medial compartment arthrosis.

METHODS

A total of 187 patients (195 knees) who underwent HTO between 1990 and 2010 were retrospectively evaluated. Eighty-eight knees, opening-wedge osteotomy with Puddu plate (group A); 51 knees, transverse osteotomy below the tubercle with external fixator (group B); and 29 knees, closing-wedge osteotomy with staple fixation (group C) were included in the study. The patients (mean age 44.9 ± 10.6 years, mean follow-up of 12.4 ± 3.2 years) were called for final controls and survival rates of the knees, and functional evaluations of the patients were performed using Knee Society Score (KSS) and Hospital for Special Surgery (HSS) knee score assessments.

RESULTS

In the comparison of the three groups, there were no differences regarding the mean age, preoperative arthrosis levels, or preoperative deformity analyses (n.s.). The main finding of these comparisons showed that the closing-wedge osteotomy has the greatest lateralization effect on mechanical axis deviation (MAD) (p = 0.024), the greatest valgization effect on medial proximal tibial angles (MPTA) (p = 0.026), and the lowest posterior tibial slope (PTS) angles (p = 0.032) in comparison to the other groups. There were no functional differences between the three groups in the long-term assessment of patients with KSS and HSS knee scores. According to the Kaplan-Meier survival analysis, the probability of the survival of the native knee joint after HTO was 93.4% in 5 years and 71.2% in 10 years in our study group. During the follow-up of the 168 knees, revision surgery with total knee replacement was needed in 27 knees (16%). The mean time from HTO to total knee replacement was 8.9 years in these patients.

CONCLUSIONS

HTO has acceptable long-term clinical and functional results that should not be underestimated by orthopedic surgeons under pressure to perform arthroplasty operations.

Comparison of HTO with articular cartilage surgery and UKA in unicompartmental OA

PURPOSE

The purpose of this article was to assess the clinical outcome of high tibial osteotomy (HTO) with articular cartilage surgery compared with unicompartmental knee arthroplasty (UKA) in unicompartmental osteoarthritis (OA).

METHODS

We designed retrospective study and evaluated 47 patients with unicompartmental OA (Kellgren-Laurence [K-L] grade ≥III OA). Two groups of patients underwent either HTO with articular cartilage surgery or UKA by the senior author between January 2010 and April 2013. The minimum follow-up period is 2 years. Clinical outcomes were assessed using Knee Injury and Osteoarthritis Outcome Scores, International Knee Documentation Committee (IKDC), and visual analog scale (VAS) score. And we evaluated the radiologic result of HTO and UKA by measuring mechanical axis at preoperative period and at last follow-up.

RESULTS

The IKDC score was significantly better in the UKA group than in the HTO group at 6 months but there was no significant difference in the two groups at 2 years. The VAS score was improved at the final follow-up compared to before surgery in both groups and did not show significant intergroup difference ( p = 0.123). There was no significant difference in the preoperative mechanical axis in the two groups. But their mechanical axis at the final follow-up were significantly different ( p = 0.0001).

CONCLUSION

The clinical outcome was significantly better in the UKA group at 6 months. But in the two groups, there were no significant differences at 12 months and 2-year follow-up, and the mechanical axis correction effect is greater than the UKA group. Based on our research, HTO with articular cartilage surgery can be considered as the treatment of choice for more active and younger patients with unicompartmental OA.

Survival and clinical outcome of isolated high tibial osteotomy and combined biological knee reconstruction

PURPOSE

We sought to determine survival and clinical outcomes of high tibial osteotomy (HTO) with or without articular cartilage surgery and/or meniscal allograft transplantation in patients with medial compartment chondral pathology, varus malalignment, and/or meniscal deficiency, whether there is any difference in survival or clinical outcome between these patient cohorts, and whether there is any difference between opening- (OWHTO) and closing-wedge (CWHTO) techniques.

METHODS

A systematic review of multiple medical databases was performed using PRISMA guidelines. Study quality was assessed via modified Coleman Methodology Scores (MCMS).

RESULTS

Sixty-nine studies were included (4557 subjects). MCMS rating was overall poor. Mean follow-up was 7.1 years. Mean subject age was 53 years. Survival of isolated HTO was 92.4%, 84.5%, 77.3%, and 72.3% at 5, 10, 15, and 20 years of follow-up. At 5 years of follow-up, HTO with articular cartilage surgery had significantly greater survival (97.7%) than either isolated HTO (92.4%) or HTO with MAT (90.9%). Isolated HTO, HTO with articular cartilage surgery, and HTO with MAT all significantly improved subjective and objective clinical outcome scores. At two years of follow-up, survival was significantly greater following OWHTO (98.7%) versus CWHTO (96.7%). However, at all other time points with or without combined articular cartilage surgery and/or MAT, there was no significant survival difference between the techniques.

CONCLUSIONS

Survival and clinical outcomes of isolated HTO were excellent at short- and mid-term follow-ups, but deteriorated with time. HTO with concomitant procedures also demonstrated excellent early survival and clinical outcomes that deteriorated with time (up to 10 years).

Comparative study of medial opening-wedge high tibial osteotomy using 2 different implants

PURPOSE

The purpose of this study was to perform a retrospective clinical and radiographic evaluation after opening-wedge high tibial osteotomy (HTO) using a short spacer plate (Aescula; B. Braun Korea, Seoul, South Korea) and rigid long plate (TomoFix plate; Mathys, Bettlach, Switzerland) at follow-up 2 years postoperatively.

METHODS

We performed 94 opening-wedge HTOs with the Aescula plate (group I) and 92 HTOs with the TomoFix plate (group II). Patients underwent clinical and radiographic evaluations preoperatively and at 2 years postoperatively. Clinical evaluations were performed with Knee Society scores. Radiographic analysis included the mechanical tibiofemoral angle (mTFA) and the slope of the tibia angle with preoperative and postoperative full weight-bearing anteroposterior whole-leg views, as well as anteroposterior, lateral, and Merchant views of the knee. We measured the mTFA. In addition, we evaluated the complications in each group. The follow-up period was 2 years.

RESULTS

At follow-up 2 years postoperatively, we observed an overall complication rate of 38% in group I and 26% in group II (P = .083). We found plate-related complication rates of 20% in group I and 9% in group II (P = .039). Plate-related complications included loss of correction, fracture of the tibial plateau, screw failure, malunion, and fracture of the lateral cortical bone. The mean mTFA was -6.0° ± 3.2° in group I and -4.6° ± 2.8° in group II preoperatively (P = .262). The mean mTFA was 1.0° ± 3.1° in group I and 1.5° ± 2.3° in group II at the latest follow-up (P = .034). In group I, the mean Knee Society knee score and function score were 60.0 ± 12.9 and 57.9 ± 26.8, respectively, preoperatively. They improved to 92.1 ± 8.1 and 89.0 ± 15.1, respectively, at follow-up (P = .001 and P = .001, respectively). In group II, the mean Knee Society knee score and function score were 57.5 ± 14.8 and 57.4 ± 22.1, respectively, preoperatively. They improved to 95.5 ± 5.4 and 95.0 ± 7.6, respectively, at follow-up (P = .001 and P = .001, respectively). In addition, the mean postoperative knee score and function score in group II were higher than those in group I (P = .001 and P = .001, respectively).

CONCLUSIONS

We have shown a high plate-related complication rate and a significant loss of correction during a short-term follow-up period (2 years) after opening-wedge HTO using the new short spacer HTO plate compared with the rigid long plate.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Comparison of high tibial osteotomy and unicompartmental knee arthroplasty at a minimum follow-up of 3 years

The purpose of this study was to compare clinical outcomes including return to recreational activities (cycling, swimming, exercise walking, dancing, jogging, and mountain climbing) after opening-wedge high tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA). Clinical outcomes were assessed using Tegner activity scores, ranges of motion, and Lysholm knee scores. In both groups, the number of patients participating in recreational activities was significantly reduced after surgery, but without a significant intergroup difference (1.3 activities in HTO group and in 1.6 activities in UKA group). Average Tegner activity scale scores, ranges of motion, and Lysholm knee scores did not show significant differences between the 2 groups. This study identified no significant differences between HTO and UKA for medial unicompartmental osteoarthritis in terms of return to recreational activity and short-term clinical outcomes.

The impact of a high tibial valgus osteotomy and unicondylar medial arthroplasty on the treatment for knee osteoarthritis: a meta-analysis

PURPOSE

Both high tibial valgus osteotomy (HTO) and unicompartmental medial knee arthroplasty (UKA) are established methods for the treatment for moderate stages of OA. This is the first global meta-analysis to compare the long-term effects of both methods regarding survival, outcomes and complications of total arthroplasty.

METHODS

Literature research was performed using established medical databases: MEDLINE (via PubMed), EMBASE (via OVID) and the Cochrane register. Criteria for inclusion were as follows: English or German papers, a clinical trial with a clear description of survival, an outcome evaluation using a well-described knee score and a follow-up >5 years. Statistical analysis was performed using the special meta-analysis software called "Comprehensive Meta Analysis" (version 2.0; Biostat, Englewood, NJ, USA).

RESULTS

Final meta-analysis after the full-text review included 46 studies about valgus HTO and 43 studies about medial UKA. There were no significant differences between valgus HTO and medial UKA in terms of the number of total required replacements. After a 5- to 8-year follow-up, 91.0% of the valgus HTO patients and 91.5% of medial UKA patients did not need a total replacement. This value was 84.4% for valgus HTOs and 86.9% for medial UKAs after a 9- to 12-year follow-up. Mean survival time to TKA was 9.7 years after valgus HTO and 9.2 years after medial UKA. Clinical outcome was significantly better after medial UKA in a 5- to 12-year follow-up. After more than 12 years, results were comparable in both groups. No significant differences were seen in the complication rates.

CONCLUSIONS

This meta-analysis aimed to find the advantages and disadvantages of two established methods for the treatment for medial compartment knee osteoarthritis. Valgus HTO is more appropriate for younger patients who accept a slight decrease in their physical activity. Medial UKA is appropriate for older patients obtaining sufficient pain relief but with reduced physical activity.

LEVEL OF EVIDENCE

II.

Fractures around the lateral cortical hinge after a medial opening-wedge high tibial osteotomy: a new classification of lateral hinge fracture

PURPOSE

The purpose of this study was to determine the frequency of lateral hinge fractures after opening-wedge high tibial osteotomy and investigate the patterns of fracture and their clinical outcome.

METHODS

We analyzed 104 knees in 93 patients with a mean age of 68 ± 7 years. Of the knees, 74 were diagnosed as having primary osteoarthritis and 30 with osteonecrosis. The mean follow-up period was 41 months. Lateral hinge fractures were classified as follows: type I, the fracture reaches just proximal to or within the tibiofibular joint; type II, the fracture reaches the distal portion of the proximal tibiofibular joint; and type III, a lateral plateau fracture. A standard postoperative rehabilitation protocol was used for type I fractures, 3 of 5 patients with type II fractures were treated with non-weight bearing, and type III fractures were treated with non-weight bearing until visible callus formation.

RESULTS

The Knee Society scores for the knee and for function showed improvement from 49 ± 11 to 91 ± 7.7 points and from 62 ± 13 to 95 ± 8.2 points, respectively. Lateral cortex fractures were observed in 26 knees (25%): 19 type I, 5 type II, and 2 type III. In the type II fracture group, 2 of 5 patients were judged to have a delayed bone union. There were 2 cases of infection (2%) and 1 case of traumatic neuroma (1%) but no instances of implant failure, nonunion, or deep vein thrombosis among our patient cohort.

CONCLUSIONS

High tibial osteotomy patients treated with a combination of TomoFix (Synthes, Bettlach, Switzerland) and bone substitute were able to walk with full weight bearing 2 weeks after surgery. No complications were seen in 19 patients with type I fractures. Of 5 patients with type II fractures, 2 had delayed unions with a correction loss of 3° and 7°, respectively.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Management of osteoarthritis of the knee in the active patient

Total knee arthroplasty has been extremely successful in elderly patients with osteoarthritis. However, there is considerable controversy regarding how best to treat the younger, athletic patient with advanced arthritis. Treatment options range from nonsurgical management with exercise and nonsteroidal anti-inflammatory drugs, to joint arthroplasty with activity modification. When properly indicated, arthroscopic débridement, high tibial osteotomy, unicondylar knee arthroplasty, and total knee arthroplasty allow younger patients with arthritis to maintain an active, healthy lifestyle.

Medial opening wedge high tibial osteotomy with early full weight bearing

PURPOSE

We performed clinical and radiographic evaluation of patients with medial compartment osteoarthritis of the knee who had undergone treatment with opening wedge high tibial osteotomy (OWHTO) followed by early full weight bearing. OWHTO procedures were performed by use of TomoFix (Synthes, Bettlach, Switzerland) and bone substitute materials.

METHODS

OWHTO was performed in 57 knees in 52 patients with a mean age of 69 years (range, 54 to 82 years) at the time of operation. The diagnosis was primary osteoarthritis in 34 knees in 29 patients and osteonecrosis in a further 23 knees in 23 patients. We established an early weight-bearing exercise program during which these patients were permitted partial weight-bearing exercise 1 week after their osteotomy procedure. All patients performed full weight-bearing exercises at 2 weeks after surgery. The mean follow-up period was 40 months (range, 24 to 62 months).

RESULTS

The American Knee Society Score and Function Score showed significant improvement from 50.9 +/- 12.3 to 91.7 +/- 6.9 points and 59.3 +/- 13.1 to 94.1 +/- 8.8 points, respectively. Before surgery, the mean femorotibial angle during standing was 181.3 degrees +/- 2.4 degrees (1.3 degrees anatomic varus), but it measured 169.6 degrees +/- 2.3 degrees (10.4 degrees valgus) at the time of follow-up. There were no instances of nonunion or implant failure in any of our patients.

CONCLUSIONS

We have shown that an early weight-bearing exercise program enables full weight bearing at 2 weeks after OWHTO with TomoFix and artificial bone wedges. Overall, this combination was a highly successful course of treatment for correcting knee malalignment in patients with medial compartment osteoarthritis.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Simultaneous bilateral opening-wedge high tibial osteotomy with early full weight-bearing exercise

Simultaneous bilateral opening-wedge high tibial osteotomies (OWHTOs), using the TomoFix fixation device and artificial bone wedges (beta-TCP) were performed on 20 knees of 10 patients with an average age of 67 years (range 53-75) at the time of the operation. We established an early weight-bearing exercise program during which patients were permitted partial weight-bearing exercise 1 week after osteotomy, with all patients performing full weight-bearing exercise at 3 weeks. The follow-up period was an average of 15 months (range 6-39). The American Knee Society Score and the Function Score were improved significantly from 46 +/- 8.1 to 92 +/- 6.8 points and 67 +/- 7.9 to 95 +/- 7.9 points, respectively. Prior to surgery, the average lateral femoro-tibial angle (FTA) during standing was 182 +/- 2.3 degrees (2 degrees anatomical varus) and significantly changed to 170 +/- 2.5 degrees (10 degrees valgus) at the time of follow-up. There were no cases of infection, non-union, or implant failure. Overall, this procedure was highly successfully in correcting knee malalignment in patients with medial compartmental osteoarthritis. In our study also, there was no evidence of correction loss, implant failure, collapse of the artificial bone wedges, or screw loosening. Simultaneous treatment of bilateral OWHTOs under a single administration of anesthesia appears to be superior to separate procedures of unilateral surgical procedures in providing the potential benefits of minimizing hospitalization, reducing costs and maximizing clinical outcomes for patients and institutions.

Computer-assisted single- or double-cut oblique osteotomies for the correction of lower limb deformities

Corrective osteotomy interventions on lower extremities are widely accepted procedures for restoring axial alignment of lower limbs. However, some studies reveal failure rates of up to 70 per cent in a 10 year time frame, which indicates that the success of corrective osteotomies depends on multiple factors. Based on a comprehensive review of error sources among conventional correction osteotomy interventions, a novel approach was developed in order to reduce these error sources among all clinical working steps (deformity determination, planning, and intra-operative realization). The article describes the implemented methodology for realizing optimal correction osteotomies based on a six-dimensional or 12-dimensional optimization module for single- and double-cut oblique osteotomies. The results show that the realized planning and navigation concept enables reduction in the error sources among the clinical working steps of correction osteotomy interventions.

Osteotomy for the Early Varus Arthritic Knee

High tibial osteotomy is a well-established procedure for the management of medial compartment arthritis that is currently experiencing a resurgence in popularity. A number of techniques have been described, with the ultimate goal of obtaining appropriate alignment to provide pain relief and functional improvement over a long-term period. Appropriate patient selection and careful surgical technique is necessary to achieve these goals with a minimal risk of complication. Newer technology such as computer navigation promises to improve the overall accuracy of the procedure. The need for alignment correction in combination with ligament reconstruction and chondral resurfacing surgery will increase the indications for this procedure. This article discusses the techniques available for high tibial osteotomy, the results and relative advantages of each, and the appropriate surgical technique to achieve optimal results while minimizing complications.